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Mr. Lansley:
That is interesting. I understand exactly what my hon. Friend has said. If there were a rationale behind the measure, the many GPs whom I have met in many places across the country would be supporting it. If it was going to provide better services for their patients, they would understand that. In some places, better services are being provided. Macclesfield is an example. My hon. Friend the Member for Macclesfield (Sir Nicholas Winterton) is not here, but if he were, he would ask us to consider what happened in his constituency. General practices there wanted to come together and create a single premises for the whole town. They have done that, and the services are there. What is happening
now? The Government say that there must be a polyclinic in every primary care trust, so the GPs in Macclesfield are threatened by the fact that the PCT wants to create another polyclinic in the PCT area. That would undermine those GPs’ situation. Frankly, that is not acceptable.
The Government made a complete mess of the GP contract. To give a simple measure of that, they paid £1.76 billion more than they were planning to. The National Audit Office reported that the Government said that under the new contract they were expecting a productivity gain in primary care of 1.5 per cent. a year. In fact, there was a drop in productivity of 2.5 per cent. in each of the first two years. The Government got the precise opposite of what they were hoping for—and we know the whole story of what happened to out-of-hours services across the country.
Interestingly, local primary care trusts that cared about open access and extended opening hours for patients—they now claim that they do—had opportunities in the contract to provide them. Local enhanced services could have commissioned Saturday morning surgeries or extended opening hours on weekdays. I find it utterly astonishing that back in February, in the midst of a conflict with the British Medical Association, I could ask the Secretary of State whether he knew whether primary care trusts had commissioned local enhanced services for extended opening hours and get the answer that he did not even know. Having not used the contract for the purpose for which it was intended, the Government now blame GPs for the costs and consequences of a contract that they negotiated and pressed GPs to accept.
Andrew George (St. Ives) (LD) rose—
Tom Levitt (High Peak) (Lab) rose—
Mr. Lansley: I talked about Cornwall, so I shall give way to the hon. Member for St. Ives (Andrew George).
Andrew George: The hon. Gentleman mentioned Cornwall, where there is concern that, as a result of the proposed package, we will end up with a private sector solution. That issue concerns me. I note the hon. Gentleman’s analysis: that the Secretary of State appears to be contradicting himself and imposing a top-down, centrally controlled solution in many areas. The Opposition motion talks about innovating in contracts with health care providers. To what extent does the hon. Gentleman believe that those contracts should include, or predominantly be, private sector contracts?
Mr. Lansley: I am talking about contracts between GPs as commissioners and the whole range of health care providers. Overwhelmingly, the contracts will be with NHS providers, although they will include private sector providers. I see absolutely no reason why there should not be an “any willing provider” policy in respect of both community provision and secondary provision.
The hon. Member for St. Ives makes an important point; in the midst of what he was asking was the question of what the consequence of the shift to large polyclinics will be. In the past couple of days, we have seen on the Department’s website evidence of how it is guiding primary care trusts to go about not only developing polyclinics but reconfiguring the whole of general
practitioner services. It is clear that it wants to do that on the basis of a small number of contracts with large providers. That is true not only for this first polyclinic, but pretty much across the board.
For a long time, the Department has wanted to get rid of the independent contractor status of GPs and turn them into salaried employees; Ministers seem now to have embraced that absurdity. Presumably, the Department is thinking that it can save a third of the cost of a GP, because a salaried GP costs only two thirds of what a principal in general practice costs. That is a dangerous route, because if practitioners lose their independent contractor status, they will find it impossible to take the position of GP budget holders or practice-based commissioners.
In November 2004, we had a debate on family doctor services in the Opposition’s time. The Government’s response then was to say, “Look how useful practice-based commissioning will be for the future.” Now we have another debate, and what is the Government’s response? It is, “Look how useful polyclinics will be in future.” Practice-based commissioning has disappeared. It has stalled across the country; more than half of primary care trusts are not giving it management support and the information to support it is not available to general practices. The proposed measure is a weak substitute for fundholding in the sense that it does not give real budgets or real incentives to save and reinvest for patients and it does not give the opportunity to innovate in contracts with health care providers.
The Government’s approach is a shameful abdication of the Government’s existing policy, which two years ago Tony Blair said was absolutely central to health care reforms. He said that there should be practice-based commissioning, but that has disappeared and is off the lexicon; instead, the Government are reverting to type and going towards a centralised, top-down, one-size-fits-all approach.
Tom Levitt: The hon. Gentleman may not have seen the briefing e-mailed in the past hour to Members by the NHS Confederation, the independent organisation representing NHS bodies. It cites the National Audit Office, which has said how successful the GP contract has been. It says that £500 million-worth of savings on the back of the contract have been fed back into new services and how for the first time the contract relates patient outcomes and curing diseases to funding. All those things are improvements brought about by the GP contract and have been cited by the NHS Confederation. They fly in the face of what the hon. Gentleman is saying.
Mr. Lansley: The NHS Confederation is “independent”, is it? It is the body that negotiated the contract and is responsible, with the Department, for the outcome. It is hardly independent. The National Audit Office is independent, and its conclusions on the contract need to be read. The contract was principally about delivering GP services where they were weakest; let me quote paragraph 4.13 of the NAO report:
“Elements of the new contract have not necessarily supported practices in deprived areas. The development of a new, needs-based funding formula was the key element of the new contract aimed at reducing inequality of provision. However, the introduction of the Minimum Practice Income Guarantee significantly reduced the redistributive impact of the formula”.
The contract has undermined the tackling of health inequalities, which were at the heart of what it was trying to deliver. I will not go on about some of the other things, but if the hon. Gentleman wants another independent view about polyclinics, I refer him to the Patients Association, which understandably sees things entirely from the patient’s point of view. Dr. Halperin, its chairman, said:
“What I believe patients want is to see their own GP, to have a regular relationship with a GP, and when they require further or more specialist treatment, to go to a hospital...what you”—
“are now doing is interposing a third layer of a polyclinic and I really don't see any advantage for it.”
Dr. Andrew Murrison (Westbury) (Con): The hon. Member for High Peak (Tom Levitt) cited the NAO and the NHS Confederation report, and he quoted selectively. Does my hon. Friend recall the NAO pointing out that the GP contract was overspent to the tune of £1.76 billion? Who does the NAO think might be to blame for that?
Mr. Lansley: We know exactly who is to blame for that—the Government. To be fair to NHS employers and the NHS Confederation, when it came down to it they were overawed by the Government, who put in their own interpretation of their estimate of the QOF—quality and outcomes framework—points that were going to be gathered by GPs. The British Medical Association, to be fair, said pretty clearly that it thought that it would be a higher figure. The difference on the QOF was about 16 per cent.—that is about 160 points, and there is £125 a point, so that is about £20,000 per GP. The Government have therefore ended up spending millions more than they ever intended. That was not simply because they got more out of the contract but because they did not put into their negotiations a proper understanding of the existing practice of GPs before they started to negotiate it.
Ann Winterton (Congleton) (Con): Will my hon. Friend give way?
Mr. Lansley: No, if my hon. Friend will forgive me, because I need to make this clear.
The purpose of this debate is not only to criticise polyclinics and how the Government are going about this but to make it clear that the House should express its support for the family doctor service and for the future of general practice, which needs to develop in future. We need to have GP commissioning; GPs must be responsible for real budgets. There is clearly an opportunity for GPs to manage care on behalf of their patients so that the relationships and continuity that they already have can be turned into something that delivers integrated care for patients and so that where services are provided they are in the best interests of patients. GPs should not be immune from competition. There should be a role for alternative providers and different models of care, but it should not be a one-size, top-down kind of care. We need patient choice of the kind that I described. Patients should be able to exercise not only choice in secondary care but choice in who is their primary care provider. We should ensure that the remuneration of GPs not only incentivises
them to be in socially and economically deprived areas looking after the patients who are most in need of their primary care services but is geared towards quality and outcomes, including patient-reported outcomes, not just the process measures that are in the QOF at the moment.
We know that primary care is highly effective—the international evidence shows that—and primary care in this country is in many respects the envy of many other countries. Primary care is instrumental to the delivery not only of high-quality care but of cost-controlled care. We can see, in this country and in others, what happens when the people making clinical decisions are not also responsible for the resource consequences. GPs can be those people. They will be well rewarded, as they are and should be, but they should have the responsibility that goes with it. They should not be treated, as the Government have treated them, as production line drones who behave only as the Government direct.
We need a future for general practice that responds to the needs of patients and to GPs’ own clinical evidence about what is in the best interests of the patients and the service. The Government use the excuse of patients wanting longer opening hours, although only 4 per cent. of patients expressed a desire for longer weekday openings. Most GPs to whom I have spoken would be happy to respond to that and would have no difficulty in doing so. Earlier this week, I spoke to a GP in Camden who said that when she went to the primary care trust and said that she wanted to open at 7 o’clock in the morning because all the patients who wanted extended hours wanted them at that time, she was told, “No, that is not good enough because the Government have told us that you’ve got to open until 8 o’clock in the evening.” She does not have any patients who want to go there at 8 o’clock in the evening—they want to arrive at 7 o’clock in the morning—but the PCT is now in such a top-down system that it will not even listen to GPs and patients.
Dr. John Pugh (Southport) (LD): Will the hon. Gentleman give way?
Mr. Lansley: No, I am sorry—I am about to conclude.
Using the excuse of the row with the BMA and the fact that GPs’ salaries appear to have increased—although we do not have the last two years’ data, when GP remuneration will have been at a static level—the Government are embarking on the destruction of the family doctor service as we know it. Access to primary care in local neighbourhoods will be lost, and rural areas will see a decline in further access to services. In many neighbourhoods in the most deprived areas, local pharmacies and local GP surgeries are among the public services that people most value and are some of the few things that really work at the moment, yet they too will disappear, as we can see from the example in the Secretary of State’s own constituency. The relationships between patients and GPs will be lost, continuity of care will be lost, and the independence of GPs will be lost and, as a consequence, the ability of primary care-led commissioning directly responsive to patients’ needs will also be lost.
Mr. Lansley: I cannot resist my hon. Friend.
Ann Winterton: There is one danger that my hon. Friend has omitted in talking about the push for polyclinics—the impact that they may have on the delivery of local services in, for example, cottage hospitals and smaller district general hospitals if the PCT commissions more services that can be delivered in polyclinics. As I am sure that my hon. Friend knows, my hon. Friend the Member for Macclesfield (Sir Nicholas Winterton) supported the first getting together of GPs on condition that that arrangement did not in any way challenge the services provided by Macclesfield district general hospital, which is also valuable to my constituency.
Mr. Lansley: I am grateful to my hon. Friend. She may have heard me refer to the GPs coming together in Macclesfield, which demonstrates what is possible if they are given the opportunity to commission services. We are not saying that there should not be change, but that it must be driven by the needs of an area. That is why we make it absolutely clear in our motion that we are opposed to a one-size-fits-all, top-down system that is not responsive to local health needs and circumstances. My hon. Friend and her very hon. Friend fight hard for the needs of their area, as can be seen in the way that they have fought not only for the GPs there but for Macclesfield district general hospital when it was threatened with reconfigurations.
The Government’s polyclinic plan will be the triumph of the one-size-fits-all approach and bureaucracy in place of clinical evidence and professionally-led—clinician-led—services. I am sorry that Government Front Benchers, in their amendment to our motion, cannot even bring themselves to support the family doctor service. They removed that from the motion where they could have left it in. In their amendment, they propagate the fallacy that the interests of GPs and patients are opposed, but they are not—GPs and patients have common interests, and patients trust GPs. There is an overwhelming sense of trust in GPs, while 97 per cent. of GPs have now reached the point where they have no confidence in the Government. That is, I am afraid, a message that the Government really should have listened to. They cannot even bring themselves to mention in their amendment the benefit of practice-based commissioning, which two years ago was a key health reform.
I am afraid that ignorance and ideology make a fatal combination. The Secretary of State has picked up the ideology of centralisation and combined it with an ignorance of general practice. When I asked about two months ago how many GP practices the Secretary of State had visited, the Minister of State, the hon. Member for Exeter (Mr. Bradshaw), told me that the Secretary of State had visited one GP practice— [ Interruption. ] I am told that it is now two.
Mr. Lansley: Not in a personal capacity—in a professional capacity.
It is entirely typical of this Government that a new Secretary of State comes in, knows absolutely nothing
about health, would prefer to be doing something different, visits one GP practice in Kingston that happens to extend its opening hours to 8 pm because it is in an area that has a lot of commuters, and draws the conclusion that every GP practice all over the country should do exactly the same thing. It is ignorance and ideology in the most absurd combination.
The Labour Government appear no longer able to understand primary care. They do not appear to value it but are none the less determined to interfere with it in the most high-handed and ideological fashion. Our motion sets out a framework for general practice. It sets out a framework of values that we are now going to encourage GPs and patients across the country to sign up to—a framework where the value of general practice is not only understood but enhanced through developing GP budget-holding and patient choice. That would be in the real interests of patients and of the NHS. I commend the motion to the House.
1.8 pm
The Secretary of State for Health (Alan Johnson): I beg to move, To leave out from “House” to the end of the Question, and to add instead thereof:
“welcomes the fact that the Government is providing £250 million, in addition to existing GP services, for 152 new state-of-the-art GP-led health centres open from 8 a.m. to 8 p.m., seven days a week; notes that these will offer a wide range of health services including prebookable GP appointments and walk-in services; further notes that where patients previously had trouble seeing their GP or had to make numerous visits to a variety of health professionals, they will now be able to see a doctor more quickly, collect their prescriptions, get their eyes tested, have a variety of diagnostic tests or see a physiotherapist in the same building and at times convenient to the patient; further welcomes the additional centrally funded 100 GP practices to be located in the most deprived areas which will have a strong focus on promoting health and reducing inequalities; acknowledges the landmark agreement with GPs to extend surgery hours in evenings and on Saturdays and agrees that extended access will benefit hardworking families; further welcomes the extension of the role of pharmacies to be able to prescribe for and deal with minor ailments on the NHS, as well as promoting good health, supporting those with long-term conditions and preventing illnesses through additional screening and advice; recognises that the Government is on the side of patients; and agrees that extending access to GP services through extended hours and new GP health centres can have a real impact on health inequalities.”
I am delighted that the Conservatives have used this Opposition day debate to allow us to highlight the investment that we are making in primary care and the measures that we are taking to give the public better access to the improved services that they require. Also, it is very good of the Conservatives to commemorate the 60th anniversary of the NHS by seeking to recreate the historical position of the Conservative party in 1948—opposed to better services for patients, defending instead the narrow vested interests of the more reactionary elements of the profession. I guess we could call it a sort of parliamentary version of the television programme, “Casualty 1907”.
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